Considering Sleep Studies for Insomnia


Michael J Thorpy, MD:We all agree that the medical history is the most important part of supporting a patient with insomnia. But there are times when we need to consider sleep studies. Vikas, when might you consider a sleep study in a patient with insomnia?

Vikas Jain, MD, FAASM, FAAFP, CCSH, CPE:I’m looking at a few things. When I get the medical history I try to get a feel for it, do you have a lot of sleep problems? Do you complain about many awakenings that seem to occur during the night? Could they complain about excessive limb movements? Or “I kick around a lot. I’m a restless sleeper.” This might get me thinking more about periodic limb motion disorders and if you’re a snorer on top of that awakening. I might consider looking for sleep related breathing disorders. I also like to consider sleep testing, more likely in patients with a long history of insomnia that has appeared unresponsive to conventional interventions with our pharmacological interventions. A few years ago, there was a study at the Mayo Clinic that showed a high prevalence of sleep disorders in many patients who had chronic insomnia for a long time. As such, it can sometimes be helpful when you’ve tried multiple interventions and wonder, “What else could there be?” This can be helpful if there is an underlying cause.

Michael J Thorpy, MD:Also, how would you diagnose sleep apnea in a patient who may be suffering from insomnia? Are there certain patients in whom this occurs more frequently?

Vikas Jain, MD, FAASM, FAAFP, CCSH, CPE:I would say it’s a lot more likely than I would think. I’ve found that there tends to be a fairly high prevalence, at least in the patients I’ve seen with refractory insomnia, who have some level of sleep disordered breathing that no one thought to look for because that person was complaining . “I can’t fall asleep” or “I can’t sleep.” No one thinks to look for sleep-disordered breathing or sleep apnea.

Nathaniel Fletcher Watson, MD: These patients may not tick all the boxes. You’re not an older, obese man who snores and is sleepy. What I’m getting at is this upper airway resistance syndrome, which could be a younger and thinner woman who isn’t being told she snores. You have some fatigue and trouble sleeping, so it can be difficult at times. But these might be the kind of people you would end up seeing with sleep-disordered breathing, where you thought you were dealing with a primary insomnia problem. Of course, in the context of this discussion, it is important to note that insomnia alone is not an indication for polysomnography. Vikas makes big points. If we see other signs that something else is going on, then we can take that path. But with the patient who comes in and has no real other risk factors or problems, we will steer away from that.

Karl Doghramji, MD: It is very important to maintain a high index of suspicion for sleep apnea related to insomnia, especially in psychiatric disorders. We know that the presence of apnea can signify underlying psychiatric disorders. For example, patients with post-traumatic stress disorder [PTSD] Patients with sleep apnea have a much worse time with PTSD than patients without sleep apnea. Eliminating their sleep apnea often helps with PTSD symptoms. These are patients who often present with a major complaint of insomnia.

Erinn E. Beagin, MD: Does it help if I ask the patient? Because this is one of the screening questionnaires for an internist to receive a home sleep study: whether they fall asleep easily during the day. Does that help distinguish if I would ask you to lie down and take a nap, if this patient with obstructive sleep apnea would be the one to shut down immediately, and maybe a primary or insomniac patient who would be more like, “You could give 20 minutes and I would still be staring at you.”

Vikas Jain, MD, FAASM, FAAFP, CCSH, CPE: I would say that insomniacs who suffer from sleep disorders generally don’t do very well on their Epworth sleepiness scale. This is a scale from 0 to 24. How likely are you to fall asleep in different situations? Most people will say, “I can never get to sleep because I have insomnia.” Sometimes people will say, “This person is an Epworth 0 or a 2 or a 4. If they’re not sleepy, why would I look for sleep-disordered breathing?” Sometimes that can fool you, so it’s very important not just to look at it.

Michael J Thorpy, MD:Certainly we must distinguish those patients who fall asleep during the day and whose main complaint is insomnia. I see patients with narcolepsy and their main complaint is trouble sleeping, but if you question them more closely you will find that they are sleepy during the day. As you mentioned, insomnia is a 24-hour problem for many patients. You can’t sleep at night. During the day they cannot sleep. For those who sleep during the day, we need to pay special attention to whether there is another underlying disease.

Transcript edited for clarity.


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